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Health Care of Children- NURS 30020- 603
A.B., an African American female was born full-term, via C-section on May 26, 2006
and is three years-and-10-months old who weighs 13 kg. She was brought by her father to the
emergency department in the evening on Sunday, April 4, 2010 due to difficulty breathing. She
presents shortness of breath and wheezing, a noise resulting from the passage of air through a
narrowed lower airway (Ball, Bindler, & Cowen, 2010). For the past two days, A.B. has been
coughing, nonproductive of any sputum. The father was attempting to aid A.B.’s symptoms by
giving her Pulmicort treatments, which is a corticosteroid that inhibits cellular response in
allergic and non-allergic-mediated inflammation. It is used for the maintenance and prophylactic
treatment of asthma (Deglin & Vallerand, 2009). Therefore, the medication was not used
correctly, and that is why A.B.’s condition was not improving, and consequently how she ended
up in the emergency department with severe difficulty breathing. The emergency department
diagnosed A.B. with an asthma exacerbation of underlying asthma.
A.B. currently lives with her father in Canton, Ohio, but lives with both her mother and
father part-time. Her parents are going through a divorce and the father is trying to gain full
custody of A.B. She has two older siblings, a brother and a sister. The parents do have an
Developmental Assessment
Developmentally, A.B. seems to be on track for her age group. According to Appendix
A, Figure A-10, A.B. is in the 25th percentile for weight at 13 kg, or 28.6 pounds; and is in the
94th percentile for stature at 38.5 inches (Ball, Bindler, & Cowen, 2010). This would put her BMI
(body mass index) at 14.03, which is in the 5th percentile according to the chart in appendix A,
Figure A-11 (Ball, Bindler, & Cowen, 2010). A.B.’s head circumference was 16.5 inches round,
which puts her in the 92nd percentile according to Figure A-6 in Appendix A (Ball, Bindler, &
According to developmental age, A.B. is at the end of the toddler stage, one to three
years, and at the beginning of the preschooler age, three to six years. Based on my subjective and
objective data, I believe A.B. is well into the preschooler category. The expectations of a three
year old in the preschooler stage and at the level of physical development would include specific
fine and gross motor ability. Some of these expected development milestones would include
being able to use scissors, draws shapes, button up shirts, brush teeth, use utensils, climb well,
and throw things overhand (Craven, & Hirnle, 2009). A.B. told me and demonstrated that she
can do all of these things; but said she has to practice at cutting with scissors and drawing shapes
so she can get better at them. Also, A.B. said it takes awhile for her to button her shirt, and that’s
why she tries not to wear those kinds of shirts.
A.B.’s psychosocial development is also on target with her age. She told me she has
many friends she plays with; this interaction is known as associative play. Communication wise,
A.B. communicated well with me and her father. She was able to hold a conversation, pay
attention, and she seemed to enjoy it. All of which are expected for her age (Ball, Bindler, &
Sigmund Freud, a psychoanalytic, theorized that all people progress through five phases,
known to be conflicts one must resolve; which are oral, anal, phallic, latent, and genital. If the
person does not resolve these conflicts, ones movement through these succeeding stages may be
unsuccessful. A.B., at age three would be at the end of the anal stage, one to three years, and at
the beginning of the phallic stage, three to six (Craven, & Hirnle, 2009). I believe A.B. has
successfully moved on to the phallic stage as she is fully potty trained and has not had an
accident of wetting herself for four months now. The phallic stage is when one is curious about
gender differences and seems to have a better relationship with the parent of the opposite sex
before the one with the same sex at this time period (Ball, Bindler, & Cowen, 2010). A.B.
seemed to have a really good relationship with her father, as I observed her telling him “I love
you” several times and giving him a few hugs. Also, she was sitting on his lap as she was eating.
Although the mother was not there for me to observe how the two of them interacted, I still
believe she is in this phase as she did not mention her mother a single time.
Nutritional Assessment
Based on my nutritional assessment, I found that A.B. seems to eat very well, but does
not look like she does. This may be due to a fast metabolism, but cannot be proven. A.B.’s father
confirmed that A.B. has a good and healthy appetite. He also stated that A.B.’s daily exercise
activity consists of running around with her brother, plays dolls, and when she blows bubbles
and chases them. According to Rolfes and Whitney, authors of Understanding Nutrition, state
that the RDA, or recommended Dietary Allowances, suggests that a three year old female should
A.B.’s father implied that she receives breakfast, a snack, lunch, another snack, dinner,
and another snack for bedtime. A.B. said she likes to drink orange juice, and eat either a pop-tart
or a bowl of cereal, preferably Trix, in the mornings for breakfast. For lunch, A.B. enjoys eating
either lunch meat on bread or a hotdog, usually with fries or a vegetable and some milk. Dinner
is when A.B. eats the best with a type of meat or pasta with vegetables and apple juice. The
snacks consist of some crackers, fruits, vegetables, or yogurt. She also enjoys drinking either
milk or juice of her choice. Her father confirmed that she only eats small portions of everything
Pathophysiology
A.B. has a history of asthma and presented to the emergency department signs of an
asthma exacerbation. Well, what is asthma? Asthma is characterized by three processes: airway
inflammation, bronchospasm, and increased mucous production. It is a chronic inflammatory
disease of the lungs causes airway obstruction and airway hyperresponsiveness. During an acute
asthma exacerbation, a trigger or a stimulus initiates an airway response that stimulates the three
processes stated above; inflammation, bronchospasm, and increased mucous production. These
triggers can vary from person to person (Ball, Bindler, & Cowen, 2010). In A.B.’s case, she had
many environmental allergies that may have stimulated this exacerbation response. These
allergies include cats, cheese, dust, eggs, fish, mold, nuts, and wheat.
When asthmatic patients’ airways detect a trigger, many things take place. First, IgE, and
mast cells will be activated and therefore, will cause the systemic immune cells to release other
mediators that cause circulating inflammatory cells to travel to the lungs. Second, bronchospasm
then occurs due to increased airway responsiveness and these mediators. These mediators also
cause hypersecretion, which then leads to increased mucous production. There is an increased
permeability in the airway. The mucous narrows the constricted airways even further, which
impairs gas exchange. Asthma is a vicious pathologic circle which must be treated to break the
cycle (Ball, Bindler, & Cowen, 2010).
The usual signs and symptoms of an asthma exacerbation is difficulty breathing with a
cough, wheezing, and breathlessness; as well as, rapid and labored breathing, tiredness, nasal
flaring, hypoxia, and possible intercostal retractions. A productive cough, prolonged expiratory
phase with wheezing, and decreased air movement may also be present (Ball, Bindler, & Cowen,
A.B., in the emergency department was found to be in marked respiratory distress with
tachypnea, decreased breath sounds, retractions, cough, wheezing, and a pulse ox of 85% on
room air, which is hypoxic. The patient’s blood pressure was 94/50, respiratory rate was 36 (H),
and pulse was in the 140-150s (H).
A.B. was diagnosed with asthma exacerbation of underlying asthma due to her physical
assessment finding, past history, and the chest x-ray that was taken. The findings included a mild
bilateral peribronchial cuffing, which indicated mild bronchial constriction.
Treatment
The usual course of treatment for an asthma exacerbation of a child at the age of three
will depend on the severity of the symptoms. In A.B.’s situation, the goal for treatment is to
correct significant hypoxemia with supplemental oxygen, a rapid reversal of airflow obstruction
by using repeated or continuous administration of an inhaled beta 2-agonist. If the patient fails to
respond to this treatment, then early administration of systemic corticosteroids is suggested.
These would include oral prednisone or intravenous methylprednisolone (Ball, Bindler, &
In the Emergency Department, A.B. was given two back-to-back treatments with
Albuterol and Atrovent. She was given oxygen of blow-by 10 liters, and given one dose of
Prelone. Her situation improved and was then admitted to the hospital for observation. She was
placed on the asthma pathway and was to begin at phase two with Albuterol. Also, they were to
Medications Classification Safe Dose Albuterol
- BronchodilationPrednisoLONE Suppress inflammation and Ibuprofen
- Decrease inflammationSingulair
- Result is decreased inflammatory process.Albuterol
Q4-6h PRN
muscle. - BronchodilationPulmicort
- used for maintenance and prophylactic treatment of asthmaPhysical Assessment
During my physical assessment of A.B., I was mainly focused on her vital signs, lung
sounds, if there was a cough present, and if it was productive or non-productive. I was focused
on these assessments due to her history of asthma and her recent asthma exacerbation. My
physical head-to-toe assessment findings of A.B. are as follows. Vital signs included pain a 0,
temperature of 37.3°C, respirations 28, pulse ox of 96%, an apical of 138, and a blood pressure
of 113/53. Her temperature was higher with my assessment compared to her previous
temperature, which was at 36.5°C. Her apical and her systolic blood pressure were also high for
a child her age. A moist, non-productive cough was present as well as some expiratory wheezes
in her upper lobes bilaterally. Her skin color was normal for her race, as well as her capillary
refill and turgor. Her abdomen was soft, round, non-tender, and active in all four quadrants. She
said her appetite is good, but I noticed she only ate about 50% of her breakfast and was not
Lab Values/Diagnostic Tests
There were no labs drawn from A.B., but there was a chest x-ray that was done. The
results were as follows: “Cardiomediastinal silhouette within normal limits. No focal
consolidation, vascular congestion or pleural effusion. No pneumothorax. Mild bilateral
peribronchial cuffing.” This cuffing can be seen in the setting of viral syndrome or reactive
Normal Growth/Normal Development
According to Banasiak and Bolster, two authors of a journal named Pediatric Asthma,
Asthma is the most prevalent chronic illness facing children in the U.S. Typically
affecting more boys than girls, it's estimated that approximately nine million
children—about 13%—under 18 years of age have asthma. Collectively, children
with asthma miss an estimated 14 million days of school each year, making it one of
the most frequent reasons for school absenteeism (2008, p. 1).
Due to this fact, many students with asthma may miss many school days. Therefore, they will get
behind in their studies and possibly be developmentally and psychosocially delayed. Also, they
may be developmentally delayed if they are frequently hospitalized. In A.B.’s case, she did not
Also, a person with Asthma could also think of themselves as an outcast, which in turn
may cause them to be lonely. If the person has many allergies or if their asthma is exercise-
induced, they may not be able to do what the other kids their age are doing. In A.B.’s case, she
has many allergies, including cats, cheese, dust, eggs, fish, mold, nuts, and wheat. She must be
cautious of what she is around and what she eats. This may affect A.B. in the future as she must
be aware of the allergens and she must be able to manage her condition. At her age, her parents
are still expected to manage her Asthma, but when she becomes older, she must know what
Also, when she gets a little older she will most likely be taught how to use a peak
expiratory flow (PEF) meter. This is used to help assess the severity of asthma, identify signs
that lung function is worsening, signal the beginning of an asthma flare, and monitor response to
treatment during an acute asthma flare (Ball, Bindler, & Cowen, 2010).
Data Grouping, Interpretation, and Nursing Diagnoses Data 1- Priority Nursing Diagnosis: Ineffective Breathing Pattern
A.B.’s primary diagnosis was Ineffective Breathing Pattern related to bronchospasm,
mucosal edema, and accumulation of mucous. The data that supports the basis for this diagnosis
was evidence of an increased work of breathing, shown my marked respiratory distress with
tachypnea presented to the emergency department. Also, decreased breath sounds, retractions,
cough, wheezing, and a pulse ox of 85% on room air, which is hypoxic. Her respiratory rate was
36, and pulse was in the 140-150s, which are both high. The increased respiratory rate,
retractions, coughing, wheezing, and low pulse oximetry, all prove A.B. was having ineffective
breathing patterns related to an asthma exacerbation, as these are all classic signs.
Ineffective Breathing Pattern related to bronchospasm, mucosal edema, and
Diagnosis:
accumulation of mucous secondary to an asthma exacerbation.
Short term
A.B. will maintain an oxygen saturation level of 95% or above during my
Interventions: 1. Intervention: Continue to administer Albuterol 3ml every 2 hours
as ordered via inhalation. Rationale: Albuterol is an adrenergic that binds beta2-adrenergic receptors in the airway smooth muscle to promote bronchodilation, which will open up the airways and allow adequate oxygenation (Deglin & Vallerand, 2009). 2. Intervention: Place A.B. in a high fowler’s position at all times. Rationale: Placing a person in an upright position promotes and
eases respiratory effort (Black, & Hawks, 2009).
3. Intervention: Continue to administer Ibuprofen 6.5ml by mouth as
needed. Rationale: Ibuprofen is a non-steroidal anti-inflammatory agent that decreases inflammation by inhibiting prostaglandin synthesis (Deglin & Vallerand, 2009). In A.B.’s case, this will help decrease the mucosal inflammation (Black, & Hawks, 2009). 4. Intervention: A focused respiratory assessment should be
performed once per shift. This would include lung sounds, skin and nail bed color, mucous membranes, cough, vital signs, especially pulse oximetry. Rationale: These assessment findings will provide an indirect way to assess oxygen level. If these findings are abnormal it indicates the oxygen level is low (Black, & Hawks, 2009). Long Term
A.B.’s respiratory status will return to a normal breathing pattern with a
normal rate, depth and ease by discharge.
Interventions: 1. Intervention: Assess A.B.’s respirations for one full minute every
two hours while observing for rate, pattern, depth, and ease. Rationale: This will allow us to see if A.B.’s condition is improving or if we need to provide more interventions to allow our goal to be reached (Black, & Hawks, 2009). 2. Intervention: Continue to administer Albuterol and Ibuprofen as
ordered. Rationale: As stated previously, Albuterol and Ibuprofen aid in bronchodilation and decreasing inflammation and therefore will allow A.B. to breath normally at a normal rate, depth, and ease (Black, & Hawks, 2009). Data 1- Implementation & Evaluation
During my time with A.B., I did many of these interventions. I made sure the bed was in
high fowler’s position, and I assessed to see if she needed the Ibuprofen, which she did not. I
also did a focused assessment that included lung sounds, skin and nail bed color, mucous
membranes, cough, vital signs, and pulse oximetry. Respiratory was in charge of giving the
Albuterol, but I was in charge of the post assessment. By doing all of these interventions, A.B.
maintained an oxygenation level of more than 95% during my shift. It was 96%. The long term
goal was also met, due to my assessment of the respirations while observing rate, pattern, depth,
and ease. By the time she was discharged, her respirations were 28, regular, and she had no
Data 2- Secondary Nursing Diagnosis: Ineffective Therapeutic Regimen Management
For A.B.’s secondary nursing diagnosis, I chose Ineffective Therapeutic Regimen
Management related to insufficient knowledge as evidenced by wrong medication given,
condition not improving, and ultimately hospitalization. The data that supports the basis for this
diagnosis was evidence that the father gave A.B. Pulmicort treatments for her acute exacerbation,
instead of Albuterol treatments. This proves that the father had insufficient knowledge about
what medication to use when in an acute exacerbation state. As I stated previously, Pulmicort is a
corticosteroid that is used only for the maintenance and prophylactic treatment of asthma (Deglin
& Vallerand, 2009). Therefore, the medication was not used correctly, and that is why A.B.’s
condition was not improving, and consequently how she ended up in the emergency department
Also, when the father was given discharge instructions about the medications, he was not
interested in what the nurse had to say. He had an appointment he had to get to on time, and was
not fully focused when receiving the information. Therefore, there is an increased chance of the
wrong medication given again by the father. According to Banasiak and Bolster, “A large
percentage of children have repeat exacerbations and continue to be poorly controlled as
outpatients, so clear and detailed explanation of care is imperative” (2008). This only proves that
explaining the management regimen is important and that compliance must take place in order to
control an asthma exacerbation another time.
Ineffective Therapeutic Regimen Management r/t insufficient knowledge
Diagnosis:
AEB an unsuccessful experience to control Asthma acute exacerbation symptoms.
Short term
A.B.’s father will verbalize when Albuterol and Pulmicort treatments are
Interventions: 1. Intervention: Instruct the father how to manage medications and
control symptoms by explaining the action of Albuterol and Pulmicort and when to use as needed. Rationale: Reeducating the father on the action and when to use the medications will clarify any misunderstandings he has about the medications and therefore, know what to do when the next exacerbation occurs (Banasiak, & Bolster, 2008). 2. Intervention: Allow the father to verbalize the action of Albuterol
and Pulmicort and when to use immediately after you re-educate him, as well as before discharge. Rationale: This will allow the father to see if he remembered and really fully understood the teaching. Also, if he remembers it before discharge, it is almost guaranteed that he will remember it when he goes home and when there is another acute exacerbation (Banasiak, & Bolster, 2008). Long Term
A.B.’s father will be able to manage A.B.’s asthma symptoms and prevent
further complications if/when A.B. exhibits another asthma exacerbation.
Interventions: 3. Intervention: Before discharge, offer the father papers talking
about what Albuterol and Pulmicort are, the actions, and when to use them. Rationale: This will give the father a paper to refer to once discharged for years to come (Banasiak, & Bolster, 2008). 4. Intervention: With the follow-up appointment, monitor A.B.’s
response to treatment, and encourage continued patient compliance with the medication regimen. Rationale: This will prove if the medications are being used properly and if the treatment is working to prevent further complications (Banasiak, & Bolster, 2008). Data 2- Implementation & Evaluation
During my time with A.B. and her father, I regret that I did not personally communicate
with the father about this situation, but I did witness the RN talking about this issue prior to
discharge. She explained what each medication was used for, but did not allow him to verbalize
the information back. I believe the short term goal was not met, as the father did not verbalize it
back, but he did say he understood. I am not sure how much he did understand, as I stated
previously, he was preoccupied with his appointment and getting out of the hospital as soon as
possible. Due to this short term goal not being met, I can assume the possibilities of the long-
Conclusion
As nurses, developing an individualized care plan for our patients is an essential tool to
being the nurse advocate. We need to assess our patients to find out what is going on and based
on that we want to come up with goals and interventions that we can implement to overall
improve the patient’s health. This nursing process paper helped me tie everything together that I
have learned throughout my student nursing career, and overall, helps you become a better nurse
in the end. One thing I must work on that I found after completing this paper, I must teach my
patients and their families anything and everything. I regret that I personally did not teach about
the action and use of Pulmicort and Albuterol. This is the main reason A.B. was hospitalized, and
I, personally, did nothing to prevent it from happening again.
Ball, J. W., Bindler, R. C., & Cowen, K. J. (2010). Child health nursing: partnering with children and families. Upper Saddle River, NJ: Pearson Education Inc.
Banasiak, N., & Bolster, A. (2008). PEDIATRIC ASTHMA. RN, 71(7), 26-32. Retrieved from
Health Source: Nursing/Academic Edition database.
Black, J.M., & Hawks, J.H. (2009). Medical-surgical nursing: Clinical management for positive
outcomes (8th ed.). St. Louis, Missouri: Saunders, Elsevier Inc.Carpenito-Moyet, L.J.,
(2008). Handbook of nursing diagnosis. Philadelphia, PA: J.B. Lippincott Company.
Craven, R.F. & Hirnle, C.J. (2009). Fundamentals of nursing: human and health function (6th
ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Deglin, J. H. & Vallerand, A.H. (2009). Davis’s drug guide for nurses. Philadelphia, PA: F.A.
Rolfes, S.R. & Whitney, E., (2008). Understanding nutrition (11th ed.)Thomson Wadsworth.